Control of Chlamydia trachomatis infections in female army recruits: cost-effective screening and treatment in training cohorts to prevent pelvic inflammatory disease

Evaluation of the Performance of the Cobas CT/NG Test for Use on the Cobas 6800/8800 Systems for Detection of Chlamydia trachomatis and Neisseria gonorrhoeae in Male and Female Urogenital Samples

The clinical performance of the Cobas CT/NG assay on the Cobas 6800/8800 systems (Cobas) for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae was established in a multisite, prospective collection study using male and female urogenital specimens; supportive data from archived specimens were also included. The results obtained with the Cobas assay were compared with the patient infected status derived from a combination of U.S.

The clinical performance of the Cobas CT/NG assay on the Cobas 6800/8800 systems (Cobas) for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae was established in a multisite, prospective collection study using male and female urogenital specimens; supportive data from archived specimens were also included. The results obtained with the Cobas assay were compared with the patient infected status derived from a combination of U.S. Food and Drug Administration-approved nucleic acid amplification tests to determine the sensitivity and specificity of detection from each sample type. The sensitivity of Cobas for the detection of C. trachomatis in female specimens was 95.6% (95% confidence interval [CI], 92.4% to 97.4%) for urine; 98.6% (95% CI, 95.2% to 99.6%) and 99.2% (95% CI, 95.4% to 99.9%) for clinician- and self-collected vaginal swab specimens, respectively; 93.3% (95% CI, 89.6% to 95.7%) for endocervical swabs; and 92.5% (95% CI, 88.7% to 95.1%) for cervical swab samples in PreservCyt. The specificity for the detection of C. trachomatis was ≥98.8% for all female sample types. Sensitivity and specificity estimates of Cobas for the detection of C. trachomatis in male urine samples were 100% (96.8% to 100.0%) and 99.7% (95% CI, 99.2% to 99.9%), respectively. The sensitivity of Cobas for the detection of N. gonorrhoeae in female specimens was 94.8% (95% CI, 89.6% to 97.4%) for urine; 100.0% (95% CI, 87.9% to 100.0%) and 100.0% (95% CI, 87.9% to 100.0%) for clinician- and self-collected vaginal swab specimens, respectively; 97.0% (95% CI, 91.5% to 99.0%) for endocervical swabs; and 96.6% (95% CI, 90.6% to 98.8%) for cervical samples in PreservCyt; the specificity for all female sample types was >99.0%. The sensitivity and specificity of Cobas for detecting N. gonorrhoeae in male urine were 100.0% (95% CI, 95.8% to 100.0%) and 99.5% (95% CI, 98.8% to 99.8%), respectively. Fully automated assays help fill the clinical need for a sensitive, high-throughput screening tool to aid public health efforts to control C. trachomatis and N. gonorrhoeae infections.

Benefit of adjunct universal rectal screening for Chlamydia genital infections in women attending Canadian sexually transmitted infection clinics

Adding universal rectal screening to urogenital screening should positively impact rectal Chlamydia trachomatis (CT) incidence in affected populations. A dynamic Markov model was used to evaluate costs and outcomes of three rectal CT screening strategies among women attending sexually transmitted infection clinics in Alberta, Canada: universal urogenital-only screening (UG-only), additional selected (exposure-based) rectal screening (UG+SR), and additional universal rectal screening (UG+UR). The model included two mutually exclusive health states: infected and susceptible. Additionally, the model included two rounds of transmission: male sex partners of women infected with rectal-only CT and female sex partners of those men. CT complications impacting patients' quality of life (QALY) were considered. Alberta and Canadian data were used to estimate model inputs. We used a health care perspective, a time period of 10 years, and a discount rate of 3% for analyses. Compared to UG-only screening, the incremental cost effectiveness ratios (ICERs) were CA$34,000 and CA$49,000 per QALY gained for UG+SR and UG+UR screening strategies, respectively. Compared to UG+SR, the ICER was CA$62,000 per QALY gained for the UG+UR strategy. Both adjunct selected and universal rectal screening strategies are cost effective compared to UG-only screening, and UG+UR screening is cost effective when compared to UG+SR screening.

Establishment of a voluntary electronic Chlamydia trachomatis laboratory surveillance system in Germany, 2008 to 2014

Chlamydia trachomatis (CT) infections are not reportable in Germany and limited data on prevalence are available. CT screening has been offered free of charge to pregnant women since 1995 and to all women under 25 years since 2008. For symptomatic women and men, diagnostic testing is covered by statutory health insurance. We describe the establishment of a nationwide, laboratory-based, voluntary sentinel that electronically collects information on all performed CT tests with test results, test reason and patient information. The sentinel represents one third of all performed CT tests in Germany. In the period from 2008 to 2014, 3,877,588 CT tests were reported, 93% in women. Women aged 20–24 years and men aged 25–29 years were the most frequently tested age groups. The overall proportion of positive tests (PPT) among women was 3.9% and among men 11.0%. The highest PPT among women was in the age groups 15–19 (6.8%) and 20–24 years (5.9%), and among men in the age groups 20–24 (19.2%), 15–19 (15.4%) and 25–29 years (14.8%). The PPT for CT was high among women and men younger than 25 years. Prevention is urgently needed. Monitoring of CT infection in Germany should be continued.

The Business Case for Quality: Combining Medical Literature Research with Health Plan Data to Establish Value for Nonclinical Managers

Clinical managers face a growing need to communicate the value of what they do in terms that can be interpreted by nonclinical financial managers. We have sought to link the evidence basis of current guidelines to variables that will demonstrate in more financial terms the very real benefit of treating diseases aggressively. We have developed an approach using the medical literature that is designed to describe clinical initiatives in more concrete terms as desired by senior management. This becomes specifically critical during budget time and when justification for various clinical programs is needed. The approach uses medical research from the peer-reviewed literature to estimate the economic impact of various initiatives and then combines the analysis with an organization's actual data to impute potential benefit. A sample grid for developing the analysis is attached. A comprehensive bibliography that will assist others with similar endeavors has been included. Although not as rigorous as formal methods, actuarial analyses, or health services research activities, it presents a beginning framework around which an organization can create operational estimates of initiative effectiveness.

Better tests, better care: improved diagnostics for infectious diseases

In this IDSA policy paper, we review the current diagnostic landscape, including unmet needs and emerging technologies, and assess the challenges to the development and clinical integration of improved tests. To fulfill the promise of emerging diagnostics, IDSA presents recommendations that address a host of identified barriers. Achieving these goals will require the engagement and coordination of a number of stakeholders, including Congress, funding and regulatory bodies, public health agencies, the diagnostics industry, healthcare systems, professional societies, and individual clinicians.

Evaluation of the Roche cobas® CT/NG test for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in male urine

BACKGROUND

The Roche cobas® CT/NG test (c4800), performed on the cobas 4800 system, is a new diagnostic assay using an automated workstation to isolate nucleic acids from clinical specimens and a real-time instrument for the detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). This study compared the performance characteristics of the c4800 with the Becton Dickinson ProbeTec™ CT/GC Q(x) assay (Q(x)) and Gen-Probe® Aptima Combo 2 (AC2) assay for the detection of CT and NG in male urine using patient-infected-status (PIS).

METHODS

Urine and urethral swabs were obtained from men attending STD, family planning, or OB/GYN clinics from 11 geographically distinct locations. Aliquot order was randomized for urine specimens between AC2, c4800, and Q(x). Urethral swabs were randomized between AC2 and Q(x). Urethral swabs were only used to define PIS and were not tested on the c4800. A participant was considered infected if the 2 comparator assays with different molecular targets had positive results from either sample type.

RESULTS

A total of 790 men were screened, with 768 evaluable for CT and NG. Symptoms were reported in 296 (38.5%) participants. For urine, the overall sensitivity and specificity of the c4800 assay for CT were 97.6% and 99.5%, respectively, when compared with PIS. Sensitivity and specificity for NG were 100% and 99.7%, respectively.

CONCLUSIONS

The c4800 has excellent sensitivity and specificity for male urine specimens when compared with PIS. Assay performance was similar in symptomatic and asymptomatic men and was equivalent to nucleic acid amplification tests that are currently on the market.

Female genital Chlamydia trachomatis infection: where are we heading?

INTRODUCTION

Urogenital infection by Chlamydia trachomatis is the most common bacterial sexually transmitted disease in the world. C. trachomatis is the etiologic agent of several common genital tract syndromes such as urethritis, cervicitis, and pelvic inflammatory disease in women.

MATERIALS AND METHODS

In this review, the pathophysiology of a chlamydial infection as well as diagnosis, therapy and prevention strategies regarding female chlamydial infection are reviewed.

RESULTS

A chlamydial infection results in minimal or even no symptoms in approximately two-thirds of women, remaining therefore clinically apparent and undiagnosed. C. trachomatis infections are of great socioeconomic and public health concern due to the potential for severe long-term consequences in women, including an increased risk of ectopic pregnancy, tubal infertility and chronic pelvic pain. Moreover, if the bacterium is transmitted during labor to a newborn, it can cause ophthalmia neonatorum and atypical neonatal pneumonia. Due to the documented increased risk of morbidity, several national guidelines are available, including a routine screening for young women and screening during pregnancy that is recommended in several countries.

DISCUSSION

A routine screening for young women and screening during pregnancy is recommended in several countries. However, additional prospective studies of the effectiveness of chlamydia screening are warranted and might be feasible within established screening programs. Moreover, the transition from cervicitis to infertility should be also evaluated in future controlled studies to underline the existing evidence. Additionally, there is an urgent need to educate and inform health-care providers about implementation of screening programs to reduce the spread of chlamydial infection. Moreover, awareness and use of screening programs by the public is needed, which requires informational campaigns for the general public using different media. For improved screening strategies and public awareness, novel approaches have to be developed and evaluated. Finally, guidelines should be actively disseminated to all medical practitioners to increase their use in daily practice. Although the major socioeconomic and public health concerns of C. trachomatis infection are recognized, several considerations and additional measures for addressing this increasingly urgent health problem remain.

Use of the internet and self-collected samples as a sexually transmissible infection intervention in rural Illinois communities

BACKGROUND

In the USA, reported cases of chlamydia (Chlamydia trachomatis) continue to rise despite substantial funding for screening. National gonorrhoea (Neisseria gonorrhoeae) rates have remained relatively stable, with clusters associated with metropolitan areas. Rural areas are no exception, as every county in Illinois reported cases of chlamydia in 2007. Morbidity associated with infection remains a public health concern, with costs of $US2.5+ billion annually. Novel screening interventions must be examined for their ability to reach those at risk who are missed by traditional methods.

METHODS

The website Iwantthekit.org was modified to allow residents from 25 contiguous counties in Central Illinois to request a self-collected sample kit. Returned kits were tested for chlamydia and gonorrhoea. The initial study period was 12 months.

RESULTS

During the study period, 343 kits were requested from 20 counties and 39.9% were satisfactorily returned for analysis. Positivity rates for chlamydia and gonorrhoea were 5.8% and 1.2%, respectively, for females and 1.9% and 0% for males. Males comprised 37.7% of all internet samples (compared with 23.4% for traditional screening venues) and 40.4% of all internet samples submitted by whites (compared with only 17.2% of traditional screening).

CONCLUSIONS

The female positivity rate was comparable to those seen in other screening venues and the method successfully engaged at-risk males. Overall, participation was low and the costs associated with the program outweighed the averted costs associated with the few cases identified. While this methodology resulted in sample requests from a wide area, it must be utilised by more individuals to become cost-effective.

A cost-effectiveness analysis of the Chlamydia Monday - A community-based intervention to decrease the prevalence of chlamydia in Sweden

Aims: The study was undertaken to assess the cost-effectiveness of the Chlamydia Monday, 2007. This is a community-based intervention aimed at reducing the prevalence of chlamydia by information and increased availability of testing, treatment and contact tracing in Stockholm. The aim was to analyze the cost-effectiveness by estimating costs, savings and effects on health associated with the intervention, and to determine if cost-effectiveness varies between men and women. Methods: A societal perspective was adopted, meaning all significant costs and consequences were taken into consideration, regardless of who experienced them. A cost-effectiveness model was constructed including costs of the intervention, savings due to avoiding potential costs associated with medical sequels of chlamydia infection, and health gains measured as quality adjusted life years (QALY). Sensitivity analyses were done to explore model and result uncertainty. Results: Total costs were calculated to be 66,787.21; total savings to 30,370.14; and total health gains to 9.852324 QALYs (undiscounted figures). The discounted cost per QALY was 8,346.05 (10,810.77/QALY for women and 6,085.35/QALY for men). Sensitivity analyses included changes in effectiveness, variation of prevalence, reduced risk of sequel progression, inclusion of prevented future production loss and shortened duration for chronic conditions. The cost per QALY was consistently less than 50,000, which is often regarded as cost-effective in a Swedish context. Conclusions: The Chlamydia Monday has been demonstrated by this study to be a cost-effective intervention and should be considered a wise use of society’s resources.

Development and Evaluation of GIS-Based Chlamydia Trachomatis Intervention Policy in Illinois

Chlamydia trachomatis is the most prevalent infectious disease in the United States. Complications include pelvic inflammatory disease (PID), ectopic pregnancy, and infertility. The cost of PID in 1998 was estimated at greater than $1.9 billion. Screening intervention strategies are often consumed by those at low risk. The objective of this study is the development of a more cost-effective intervention strategy by employing Geographic Information Systems and Census Bureau demographic data in selected Local Health Departments in Illinois. Case studies of intervention activities at the state and local level were performed. An evaluability assessment model of current inputs, processes and outcomes was created. A proposed model utilizing additional state inputs was developed and tested. Interventions were evaluated for effectiveness in reducing the incidence of Chlamydia trachomatis. Societal cost effectiveness analysis was also performed. The proposed model was tested in 2006. Results indicate that only minimal changes in annual incidence are required for GIS-augmented interventions to be cost-effective.

Cost-effectiveness of screening strategies for Chlamydia trachomatis using cervical swabs, urine, and self-obtained vaginal swabs in a sexually transmitted disease clinic setting

BACKGROUND

We evaluated the cost-effectiveness of Chlamydia screening strategies that use different methods of specimen collection: cervical swabs, urines, and self-obtained vaginal swabs.

METHODS

A decision analysis was modeled for a hypothetical cohort of 10,000 per year of women attending sexually transmitted disease (STD) clinics. Incremental cost-effectiveness of 4 screening strategies were compared: 1) Endocervical DNA probe test (PACE2, Gen-Probe), 2) Endocervical AC2 (Aptima Combo 2, Gen-Probe), 3) Self-Obtained Vaginal AC2, and 4) Urine AC2. Sensitivities of the vaginal, urine, and cervical AC2 tests were derived from 324 women attending STD clinics. The primary outcome was cases of pelvic inflammatory disease prevented. The model incorporated programmatic screening and treatment costs and medical cost savings from sequelae prevented.

RESULTS

Chlamydia prevalence in the sampled population was 11.1%. Sensitivities of vaginal, urine, and cervical AC2 were 97.2%, 91.7%, and 91.7%, respectively. The sensitivity of the DNA probe was derived from the literature and estimated at 68.8%. The self-obtained vaginal AC2 strategy was the least expensive and the most cost-effective, preventing 17 more cases of pelvic inflammatory disease than the next least expensive strategy.

CONCLUSIONS

Use of a vaginal swab to detect Chlamydia in this STD clinic population was cost-saving and cost-effective.

Should asymptomatic men be included in chlamydia screening programs? Cost-effectiveness of chlamydia screening among male and female entrants to a national job training program

OBJECTIVE

To compare the cost-effectiveness of various chlamydia screening strategies within a population of male and female youth entering a national job training program.

STUDY DESIGN

Cost-effectiveness analysis of various chlamydia screening strategies among a cohort of 4000 female and male New England job training students. Strategies for women include (a) no screening, (b) universal endocervical DNA probe screening, (c) universal urine based NAAT screening, and (d) universal endocervical NAAT screening. Strategies for men include (a) no screening, (b) selective urine NAAT screening of leukocyte esterase (LE)-positive urines, and (c) universal urine-based NAAT screening.

RESULTS

Universal endocervical NAAT screening of women and universal urine NAAT screening of men were the most effective and cost-effective strategies individually and in combination. Endocervical NAAT screening of women prevented 23 more cases of PID and saved $27,000 more than endocervical DNA probe screening. Likewise, universal urine NAAT screening of men prevented 21 more cases of PID in their female partners and saved $16,000 more than selective urine NAAT screening of LE positive men.

CONCLUSIONS

Use of a sensitive NAAT to screen both men and women for chlamydia upon entry to a National Job Training Program is cost-effective, cost-saving, and provides a public health opportunity to substantially reduce chlamydia infections among youth at risk for sexually transmitted diseases.

One to one interventions to reduce sexually transmitted infections and under the age of 18 conceptions: a systematic review of the economic evaluations

OBJECTIVE

To systematically review and critically appraise the economic evaluations of one to one interventions to reduce sexually transmitted infections (STIs) and teenage conceptions.

DESIGN

Systematic review.

DATA SOURCES

Search of four electronic bibliographic databases from 1990 to January 2006. Search keywords included teenage, pregnancy, adolescent, unplanned, unwanted, cost benefit, cost utility, economic evaluation, cost effectiveness and all terms for STIs, including specific diseases.

REVIEW METHODS

We included studies that evaluated a broad range of one to one interventions to reduce STIs. Outcomes included major outcomes averted, life years and quality adjusted life years (QALY). All studies were assessed against quality criteria.

RESULTS

Of 3,190 identified papers, 55 were included. The majority of studies found one to one interventions to be either cost saving or cost effective, although one highlighted the need to target the population to receive post-exposure prophylaxis to reduce transmission of HIV. Most studies used a static approach that ignores the potential re-infection of treated patients.

CONCLUSION

One to one interventions have been shown to be cost saving or cost effective but there are some limitations in applying this evidence to the UK policy context. More UK research using dynamic modelling approaches and QALYs would provide improved evidence, enabling more robust policy recommendations to be made about which one to one interventions are cost effective in reducing STIs in the UK setting. The results of this review can be used by policy makers, health economists and researchers considering further research in this area.

Universal screening or prophylactic treatment for Chlamydia trachomatis infection among women seeking induced abortions: which strategy is more cost-effective?

OBJECTIVE

The objective of this study was to evaluate the cost-effectiveness of universal screening and azithromycin-based prophylaxis against no intervention for Chlamydia trachomatis infection among women seeking induced abortions.

METHODS

A decision tree was constructed to evaluate health effects of the program. Cost-effectiveness was estimated for universal screening and azithromycin-based prophylaxis against no intervention with a C. trachomatis test prevalence of 4.8%.

RESULTS

Azithromycin-based prophylaxis produced higher cost but prevented 289 cases of pelvic inflammatory disease (PID) for a cost of 397 RMB (U.S. $48) per case of PID prevented over no intervention. Universal screening by polymerase chain reaction test prevented 253 cases of PID at a cost of 3,049 RMB (U.S. $372) per case of PID prevented over no intervention. Azithromycin-based prophylaxis prevented an additional 36 cases of PID, costing 18,239 RMB (US $2,224) less per case of PID prevented over universal screening.

CONCLUSIONS

Azithromycin-based prophylaxis provided a cost savings over universal screening for chlamydial infection among women seeking induced abortion.

Prevalence of Chlamydia trachomatis Among Active Duty Male Soldiers Reporting to a Troop Medical Clinic for Routine Health Care

OBJECTIVE

To determine the prevalence of chlamydia among young, male soldiers receiving routine healthcare and to measure risk factors associated with sexually transmitted infections (STI).

MATERIALS AND METHODS

Male soldiers between the ages of 18 to 25 years seeking routine healthcare were screened for chlamydia. Educational information regarding Chlamydia trachomatis was provided before testing. The transcription-mediated amplification (TMA) urine-based test was used as a sensitive and specific screening tool to detect disease. Assessment of risk factors was determined by questionnaire. Subjects who tested positive for chlamydia were treated with azithromycin 1 g in a single dose.

RESULTS

A total of 138 male soldiers were screened for chlamydia. The majority of soldiers screened reported to sick call for evaluation of an injury, 31.9%. The estimated prevalence of chlamydia was 8.0% (95% CI: 0.035-0.125). Soldiers who tested positive for chlamydia were more commonly asymptomatic, 72.7%. Of those who screened positive for chlamydia, 63.6% did not use a condom during their last encounter. No subjects who tested positive for disease had been treated for an STI in the past.

CONCLUSIONS

The prevalence of chlamydia in this population of young, male soldiers is high. These results should spur providers to incorporate STI risk assessment and screening into a variety of clinical encounters.

Screening for Chlamydia trachomatis: a systematic review of the economic evaluations and modelling

OBJECTIVE

To review systematically and critically, evidence used to derive estimates of costs and cost effectiveness of chlamydia screening.

METHODS

Systematic review. A search of 11 electronic bibliographic databases from the earliest date available to August 2004 using keywords including chlamydia, pelvic inflammatory disease, economic evaluation, and cost. We included studies of chlamydia screening in males and/or females over 14 years, including studies of diagnostic tests, contact tracing, and treatment as part of a screening programme. Outcomes included cases of chlamydia identified and major outcomes averted. We assessed methodological quality and the modelling approach used.

RESULTS

Of 713 identified papers we included 57 formal economic evaluations and two cost studies. Most studies found chlamydia screening to be cost effective, partner notification to be an effective adjunct, and testing with nucleic acid amplification tests, and treatment with azithromycin to be cost effective. Methodological problems limited the validity of these findings: most studies used static models that are inappropriate for infectious diseases; restricted outcomes were used as a basis for policy recommendations; and high estimates of the probability of chlamydia associated complications might have overestimated cost effectiveness. Two high quality dynamic modelling studies found opportunistic screening to be cost effective but poor reporting or uncertainty about complication rates make interpretation difficult.

CONCLUSION

The inappropriate use of static models to study interventions to prevent a communicable disease means that uncertainty remains about whether chlamydia screening programmes are cost effective or not. The results of this review can be used by health service managers in the allocation of resources, and health economists and other researchers who are considering further research in this area.

The impact of natural history parameters on the cost-effectiveness of Chlamydia trachomatis screening strategies

OBJECTIVE/GOAL

To understand the potential impact of assumptions about the natural history of untreated Chlamydia trachomatis on the cost-effectiveness of screening strategies.

STUDY DESIGN

Using a previously developed state-transition model, we explored how alternative assumptions about the natural history of disease following infection affect the estimated cost-effectiveness of screening for U.S. women. The analysis was conducted from a modified societal perspective and incorporated a lifetime analytic horizon.

RESULTS

Different natural history assumptions affect cost-effectiveness outcomes. Assumptions about the combined risk of persistent and repeat infections have the greatest impact on the composition of optimal screening strategies, whereas assumptions about the risk of pelvic inflammatory disease most greatly influenced the magnitude of incremental cost-effectiveness ratios.

CONCLUSIONS

Priorities for future C trachomatis research should include better estimates of the risk of pelvic inflammatory disease, persistence, and repeat infection. Better delineation of these variables will permit improved evaluation of potential screening activities.

Women presenting with lower abdominal pain: A missed opportunity for chlamydia screening?

INTRODUCTION

Many young women presenting with lower abdominal pain are referred to general surgeons with possible appendicitis. For some of these patients there will be a gynaecological cause for their pain. There has been a steady increase in the incidence of Chlamydia infections and pelvic inflammatory disease (PID) among the general population. Therefore, are general surgeons considering this as a diagnosis for lower abdominal pain in women?

METHODS

One hundred and ninety three women who had been admitted with lower abdominal pain to a single hospital between 1999 and 2001 were identified using computerised records and the notes were examined. One hundred and eighty six women were included in the audit. Investigations and treatments instigated for these patients were then carefully recorded.

RESULTS

Seventy-four patients underwent appendicectomy, of which 59 were histologically confirmed. Eighty-nine patients (47.8%) of admissions had no final diagnosis and were not screened for Chlamydia trachomatis. Sexual history was recorded in only 51% of admissions. Vaginal swabs were sent in only 7.3% of admissions.

CONCLUSION

Current guidelines for Chlamydia trachomatis screening produced by the Chief Medical Officer (CMO) include screening in women presenting with lower abdominal pain as well as those with post-coital or intermenstrual bleeding. Most women who present with classical symptoms of PID will present to gynaecological specialities for further management. However, a significant number of women presenting atypically will be referred to surgeons to exclude gastrointestinal causes for their lower abdominal pain. These women could and probably should be screened for Chlamydia trachomatis.

Biomedical Research on Health and Performance of Military Women: Accomplishments of the Defense Women's Health Research Program (DWHRP)

In 1994, Congress provided dollar 40 M for biomedical research on issues of importance for military women. This supported 104 intramural and 30 extramural studies and launched an era of research to narrow the knowledge gap on protection and enhancement of health and performance of military women. Projects addressed issues specific to female physiology (e.g., gynecological health in the field, maternal malaria), problems with higher prevalence for women (e.g., marginal iron deficiency, stress fracture), and issues of drug and materiel safety that had only been extrapolated from studies of men (e.g., chemical agent prophylaxis, fatigue countermeasures). Several important assumptions about female physiology and occupational risks were found to be astoundingly wrong. Hormonal changes through the menstrual cycle were less important to acute health risks and performance than predicted, exercise did not increase risk for amenorrhea and consequent bone mineral loss, and women tolerated G-forces and could be as safe as men in the cockpit if their equipment was designed for normal size and strength ranges. Data on personal readiness issues, such as body fat, physical fitness, nutrition, and postpartum return to duty, allowed reconsideration of standards that were gender appropriate and not simply disconnected adjustments to existing male standards. Other discoveries directly benefited men as well as women, including development of medical surveillance databases, identification of task strength demands jeopardizing safety and performance, and greater understanding of the effects of psychosocial stress on health and performance. This surge of research has translated into advances for the welfare of service women and the readiness of the entire force; relevant gender issues are now routine considerations for researchers and equipment developers, and some key remaining research gaps of special importance to military women continue to be investigated.

Nucleic acid amplification tests for gonorrhea and chlamydia: practice and applications

Nucleic acid amplification tests (NAATs), which are highly sensitive and specific, have provided the ability to use alternative sam-ple types for the diagnosis of sexually transmitted infections (STIs). Self-collected genital specimens, such as urine or even vaginal swabs, can now be accurately used to diagnose gonorrhea or chlamydia infections. In many cases, use of these sample types can decrease the necessity for a clinician to perform a pelvic examination on women or to collect a urethral swab from men, thus extending the diagnostic capability for detecting these infections to nonclinic screening venues. As most chlamydia infections and many gonorrhea infections are asymptomatic, the use of NAATs for self-collected samples greatly increases the types and numbers of patients that can be screened outside of clinic settings. Self-sampling also allows clinicians to easily screen patients in the clinic for STIs who are not presenting for pelvic or urogenital examinations. The application of NAATs to self-collected specimens has the potential to augment public health programs designed to control the epidemic of STIs in the community.

The Cost Effectiveness of Gonorrhea Screening in Urban Emergency Departments

BACKGROUND

The prevalence of gonorrhea (GC) among adolescent and young women attending some urban emergency departments (EDs) ranges from 1% to 7%, but historically screening has not been logistically practical.

GOAL

The primary goal of the study was to assess the cost effectiveness of GC screening in women ages 15 to 29, seeking care in urban EDs, using noninvasive or rapid point-of-care tests.

STUDY

We developed a state-transition Markov model to compare the net lifetime health consequences, costs, and cost effectiveness of routine ED care (no screening for women without genitourinary symptoms) to GC screening using 1 of 5 detection methods: Gram-stained smears of endocervical swab specimens, urine-based nucleic acid amplification tests (NAATs), NAATs performed on endocervical swabs, rapid immunochromotographic strip test (RIS) performed on clinician-collected vaginal swabs, and RIS on patient-collected vaginal swabs.

RESULTS

Screening women between 15 and 29 years of age using urine-based NAATs prevented 1247 cases of pelvic inflammatory disease (PID) and saved 177 US dollars per patient compared with no screening. Compared with urine-based NAAT, screening with RIS using clinician-obtained vaginal swabs prevented an additional 220 cases of PID and had an incremental cost effectiveness ratio of 6490 US dollars per quality-adjusted life year (QALY). Results were sensitive to assumptions about loss to follow-up, gonorrhea prevalence, and test costs.

CONCLUSION

Screening females aged 15 to 29 for gonorrhea in some urban EDs will prevent substantial reproductive morbidity. Screening with rapid, point-of-care tests is cost effective compared with other well-accepted preventive interventions.

Comparison of DNA extraction from cervical cells collected in PreservCyt solution for the amplification of Chlamydia trachomatis

OBJECTIVE

The aim of this study was to compare and evaluate three methods of DNA extraction for the amplification of Chlamydia trachomatis in uterine cervical samples collected in PreservCyt solution. ThinPrep is the trade name for the slide preparation.

METHODS

Thirty-eight samples collected in LCx buffer medium, which were identified as C. trachomatis infected by ligase chain reaction (LCR), were selected for this study. DNA from the PreservCyt samples was extracted by three methods: (i) QIAamp kit, (ii) boiling in Tris-EDTA buffer with Chelex purification, and (iii) Proteinase K digestion with Chelex purification. Sample DNA was tested for the presence of C. trachomatis by PCR using cryptic plasmid research (CTP) primers and major outer membrane protein research momp gene (MOMP) primers. Real-time (LightCycler) PCR for relative C. trachomatis quantification following DNA extraction was performed using primers (Hsp 60) for the 60 kDa heat-shock protein hsp60 gene.

RESULTS

Amplification using CTP primers was the most successful with each of the extraction protocols. Boiling in buffer was the least successful extraction method. QIAamp was the best extraction method, yielding the most positives with both the CTP and MOMP primers. Proteinase K-Chelex extraction gave similar sensitivity to QIAamp extraction with CTP primers but lower for MOMP primers.

CONCLUSIONS

The DNA extraction method must be carefully selected to ensure that larger PCR amplicons can be successfully produced by PCR and to ensure high sensitivity of detection of C. trachomatis. In this study it was found that the QIAamp extraction method followed by PCR with the CTP primers was the most successful for amplification of C. trachomatis DNA.

A Swedish cost-effectiveness analysis of community-based Chlamydia trachomatis PCR testing of postal urine specimens obtained at home

AIMS

A study was undertaken to assess the cost-effectiveness of identifying and treating asymptomatic carriers of Chlamydia trachomatis when using community-based testing of urine specimens obtained at home and mailed to a central laboratory.

METHODS

A total of 100 males and 100 females aged 20-24 living in Umeå were randomly sampled from the population registry. A societal cost-effective analysis was carried out, based on screening and medical care costs in Sweden.

RESULTS

With a participation rate of 55% (45% males and 65% females), the female screening became cost-saving as the C. trachomatis prevalence exceeded 5.1%, and the male screening became cost-saving with over 12.3% prevalence.

CONCLUSION

Postal screening for C. trachomatis in an asymptomatic young population can be cost-effective only at prevalences higher than at present.

Urine nucleic acid amplification tests for the diagnosis of sexually transmitted infections in clinical practice

PURPOSE OF REVIEW

With the advent of highly sensitive and specific nucleic acid amplification assays, this report will demonstrate that self-collected genital specimens, such as urine or even vaginal swabs can be accurately used to diagnose sexually transmitted infections.

RECENT FINDINGS

Use of self collected samples can eliminate the necessity of a clinician to perform a pelvic examination for women or collect a urethral swab for men, thus extending the diagnostic capability for sexually transmitted infections to non-clinic screening venues. As many sexually transmitted infections are asymptomatic, this ability to use self-sampling greatly increases the numbers of patients that can be screened, and has the potential to augment public health programs designed to control the epidemic of sexually transmitted infections in the community. Patient collected samples are highly acceptable, highly accurate, and are becoming widely used. Self-sampling also allows clinicians to easily screen patients in the clinic, who are not presenting for pelvic or urogenital examinations, for sexually transmitted infections.

SUMMARY

Highly accurate molecular tests and easily obtained self-collected urogenital samples represent the ideal combination for obtaining the public health goal of decreasing the sexually transmitted infection epidemic among sexually active persons in the United States today.

Feasibility and Short-Term Impact of Linked Education and Urine Screening Interventions for Chlamydia and Gonorrhea in Male Army Recruits

OBJECTIVE

The objective of this study was to assess the feasibility of an intervention for sexually transmitted diseases (STDs) and a screening program for Chlamydia trachomatis and Neisseria gonorrhoeae infections in male Army recruits.

GOALS

The goals of this study were to identify and treat chlamydia and gonorrhea infections in recruits, assess their perceptions of risk, and increase their STD knowledge and behavioral intentions.

STUDY DESIGN

Volunteers (n = 3911) entering basic training (July 1999-June 2000) at Fort Jackson, South Carolina, attended an educational intervention, completed pre- and post-questionnaires, and provided a urine specimen for chlamydia and gonorrhea screening by nucleic acid amplification testing.

RESULTS

Chlamydia and gonorrhea prevalences were 4.7% and 0.4%, respectively. The mean STD knowledge score, intent to use condoms, and confidence in using condoms correctly increased (P <0.001). Participants reported increased risk perception and considered the educational program valuable (96.9%) and a learning experience (94.6%).

CONCLUSIONS

A linked educational and screening program is feasible and acceptable in male Army recruits.

Developments in the screening for Chlamydia trachomatis: a review

Many studies have evaluated selective screening criteria for women in various settings. Most have concluded and all guidelines recommend that all women aged < 25 be screened yearly for C. trachomatis infection. Behavioral criteria, such as the number of sex partners, new or more than one sex partners, and previous infection, also can serve as criteria for screening women aged > 25. Because re-infection rates are high and occur within a few months, complications may be reduced further if partners are treated and women rescreened 4 to 6 months after initial infection. Revised recommendations for C. trachomatis screening programs have stated that more frequent screening may be considered among women < 20 and those with recent infection. Screening in nontraditional settings and careful evaluation of local prevalence and risk factor information should be encouraged. Private providers and emergency room providers should discuss screening recommendations and adopt a C. trachomatis screening policy for the population they serve. The HEDIS measure should serve to encourage at least annual screening of 15- to 25-year-old sexually active females through providers linked to managed care organizations. In general, high yields (ie, percentage of tests that are positive) in nontraditional settings and enhanced feasibility and acceptability of urine-based tests may encourage further innovative approaches to reach and screen populations at risk. Several issues remain to be addressed to increase the effectiveness of screening efforts. If more sensitive amplification tests are used widely, more infected persons will be identified and treated, and transmission patterns may change, particularly if partner treatment also occurs. Current screening criteria should continue to be re-evaluated. An important issue that affects testing methods includes the possible need for confirmation testing when using NAATs if the prevalence of C. trachomatis is less than 2%. If the sensitivity of an NAAT is 85% and specificity is 99%, in a hypothetical population of 10,000 with a prevalence of 2%, the positive predictive value is 170/268 (63%). A second important issue affecting testing methods and feasibility of using NAATs for screening large numbers of individuals is the pooling of urine specimens, which has been evaluated in several studies and found to be very effective for reducing costs. A research issue for pooling is the determination of the most cost-effective prevalence levels for pooling. An additional research question is in which populations should a NAAT be used for detection of C. trachomatis and N. gonorrhoeae. There are no recommendations for the routine screening of men because of the paucity of data showing that this strategy can reduce sequelae. The CDC is conducting a multisite study to examine the feasibility, acceptability, and usefulness of screening of asymptomatic men. There are a few studies have determining cost-effective prevalence threshold levels, particularly with NAATs. A recently developed decision analysis model by CDC designed to maximize the effectiveness of screening strategies for C. trachomatis infections may be useful for decision makers. It is intended to serve as an easy and flexible tool to determine cost effectiveness at a local level and takes into account positivity rates and test performance characteristics (SOCRATES). It is unclear if recurrent infection is caused by true re-infection by the same or a different partner or recurrence of initial infection. Recurrence may be caused by persistence of C. trachomatis or antibiotic resistance. This distinction is of scientific interest because the appropriate intervention differs (eg, identification of risk factors for the former and microbiologic investigations for the latter). Effective partner management and retesting are critical to reducing sequelae of C. trachomatis infection. Screening for C. trachomatis infection remains an essential component of C. trachomatis control. It is cost effective, most infections are asymptomatic, and symptom-based health care seeking and testing identify few of those infected. The likelihood that opportunities for screening are missed is high particularly in non-STD clinic settings. Local studies using NAATs to determine C. trachomatis prevalence and risk factors are helpful to health care providers so they can make evidence-based decisions on who to screen. The use of nontraditional, non-clinic-based test settings should be explored further. We have focused on summarizing the medical evidence regarding recommendations for screening for C. trachomatis. High-risk populations for C. trachomatis infection may overlap with populations for other STDs, and comprehensive STD prevention programs that involve a range of STD service providers are needed to successfully reduce the STD-related health burden in the population.

Cost-Effectiveness Analysis of Screening Adolescent Males for Chlamydia On Admission to Detention

BACKGROUND

Chlamydia trachomatis infections can lead to serious and costly sequelae. Because chlamydia is most often asymptomatic, many infected youth do not seek testing. Entry to a detention system provides an opportunity to screen and treat many at-risk youth. GOAL The goal of this study was to determine the cost-effectiveness of screening male youth for chlamydia on entry to detention.

STUDY DESIGN

Incremental cost-effectiveness of 3 chlamydia screening strategies was compared for a hypothetical cohort of 4000 male youth per year: 1) universal chlamydia screening using a urine-based nucleic acid amplification test (NAAT), 2) selective NAAT screening of urine leukocyte esterase (LE)-positive urines, and 3) no screening. The model incorporated programmatic costs of screening and treatment and medical cost savings from sequelae prevented in infected males and female partners. The analysis was conducted from the healthcare system perspective.

RESULTS

Chlamydia prevalence in the sampled population of 594 was 4.8%, and the average number of female sexual partners/infected male was 1.6. Universal NAAT screening was the most cost-effective strategy, preventing 37 more cases of pelvic inflammatory disease (PID) and 3 more cases of epididymitis than selective screening and saving an additional 24,000 dollars. The analysis was sensitive to NAAT cost, LE sensitivity, rate of PID development, PID sequelae cost, and number of female partners. Universal screening remained the most cost saving for prevalence as low as 2.8% or higher.

CONCLUSIONS

Universal chlamydia screening of adolescent males on entry to detention was the most cost-effective strategy. Savings are primarily the result of the prevention of PID in recent and future partners of index males. Screening detained male youth using a urine-based NAAT provides a public health opportunity to significantly reduce chlamydia infections in youth at risk for sexually transmitted diseases.

Prevalence of Chlamydia trachomatis infections and specimen collection preference among women, using self-collected vaginal swabs in community settings

BACKGROUND

Chlamydia trachomatis is a common, often asymptomatic sexually transmitted infection.

GOAL

The goal was to estimate the prevalence and predictors of C. trachomatis among young women using self-collected vaginal swabs, and the preferences of women and physicians for self-testing.

STUDY DESIGN

A total of 514 attendees of university/college health clinics, adolescent birth control clinics, centers providing health services to homeless youth and adults (street health centers), a sexually transmitted diseases clinic, and family practices were tested by ligase chain reaction. Preference for self- versus provider-testing was examined.

RESULTS

Prevalence was 6.0% and was highest (18.2%) in the street health centers. In multivariate analysis, only recent contact with someone with C. trachomatis infection was significantly associated with infection (odds ratio, 7.1; 95% confidence interval, 2.5-20.0). Most women (54.2%; 256 of 472) preferred self-sampling compared with physician sampling (15.9%; 75 of 472). The majority of physicians (75.0%; 9 of 12) reported at the start and end of the study that they would use vaginal swab self-sampling if available.

CONCLUSIONS

Prevalence of infection in young women attending homeless youth organizations was high. Self-sampling was acceptable and could facilitate screening in high-risk women who do not regularly access health services.

Preference among female Army recruits for use of self-administrated vaginal swabs or urine to screen for Chlamydia trachomatis genital infections

BACKGROUND

Use of self-administered vaginal swabs (SAS) for the detection of Chlamydia trachomatis by nucleic acid amplification tests simplifies specimen collection and transport, especially for women in nonclinical settings.

GOAL

We investigated the preference and comfort level of military women for the collection of SAS, compared with urine, for the diagnosis of genital chlamydial infections.

STUDY DESIGN

During March through August 1999, female Army recruits in basic training at Fort Jackson, South Carolina, were invited to participate in the study. Participants were requested to complete a questionnaire after providing both first-void urine (FVU) and SAS specimens. Participant characteristics, preferences, and comfort levels were assessed using multivariate logistic regression.

RESULTS

From 4496 eligible female recruits, 1403 (31%) completed questionnaires and 1382 provided both specimens; 11.8% (166 of 1403) of participants were infected with chlamydia. The relative sensitivity and specificity of the C. trachomatis Ligase Chain Reaction test on SAS in 1382 matched pairs was 81.1% and 98.6%, respectively, using the test result on urine specimens as the comparison standard. Most of the participants (90.8%) reported that they felt comfortable collecting the FVU specimen, and 69.6% indicated that they felt comfortable collecting SAS. Either specimen collection type received high acceptability at home and in the field, and more women reported that they would collect FVU than reported they would collect SAS in the future (in the field: FVU: 79.4%, SAS: 68.8%, P <0.001); at home: FVU: 90.9%, SAS: 82.9%, P <0.001). When questioned about ease of use, 60.4% of women reported that urine was the easier method. Preferences for SAS were associated with being white and having had sexual risk behaviors in the past 3 months.

CONCLUSION

A study of preferences for urine versus self-administered vaginal swabs for the detection of C. trachomatis in military women showed that women generally found SAS acceptable. SAS should be a feasible alternative to urine collection in situations in which specimen storage or transport is an issue.

Sustained high prevalence of Chlamydia trachomatis infections in female army recruits

BACKGROUND

Chlamydia trachomatis infections are prevalent among young sexually active females, have serious sequelae, and are mostly asymptomatic. Screening and treatment of infected females has been demonstrated to prevent sequelae such as pelvic inflammatory disease.

GOAL

To assess prevalence and risk factors for chlamydia infection in US Army female recruits, whether these changed over time, and to examine variables contributing to any observed patterns.

STUDY DESIGN

Prevalence study of 23,010 non-healthcare-seeking female Army recruits enrolled in a chlamydia screening program at Fort Jackson, SC, from January 1996 through June 1999. Each of the 4-year cohorts was examined separately for prevalence and risk factors.

MAIN OUTCOME MEASURES

Urine-based testing for C trachomatis by ligase chain reaction was used to determine prevalence, and questionnaires were used to collect demographic and risk information. State home of record for each recruit was transformed into Public Health reporting region: West, Midwest, South, Northeast, and Territories.

RESULTS

Prevalence for all years was 9.51%, but a progressive increase from 8.51% to 9.92% occurred over the course of study (P=0.018). The proportion of individuals reporting specific risk factors during the 90 days preceding the study generally decreased over time. In a regression model, significant risk factors for infection included black race, age 25 years or younger, home-of-record from the South, being screened during years 3 and 4 of the study, more than one sex partner, a new sex partner, and history of any sexually transmitted disease. Condom use was protective. In another model controlling for age and home-of-record from the South, being screened in years 2, 3, and 4 of the study were significantly predictive for being chlamydia positive.

CONCLUSION

A high and slightly increasing prevalence of C trachomatis infection was observed among young females entering the military over 4 consecutive years. Young age, black race, home-of-record from the South, more than one sex partner, a new sex partner, condom use, and a history of having a sexually transmitted disease were correlates of chlamydia infection. Sustained high rates of C trachomatis infection in this population provide clear justification for a chlamydia control program for young women entering the Army consisting of screening at entry on the basis of age and possibly home-of-record together with continued periodic rescreening.

SUMMARY

A study of 23,010 female Army recruits demonstrated that a high prevalence of C trachomatis was sustained during 4 years of observation. Year of study, young age, and being from the South were significant predictors of infection.

A refined estimate of the average lifetime cost of pelvic inflammatory disease

BACKGROUND

The major complications of pelvic inflammatory disease (infertility, ectopic pregnancy, and chronic pelvic pain) are the leading cause of non-HIV sexually transmitted disease morbidity in the United States.

GOAL

The goal of the study was to estimate a plausible range for the average lifetime cost of pelvic inflammatory disease (PID) and its major complications in a cohort of U.S. women of reproductive age.

STUDY DESIGN

We developed a state-transition computer-based model to simulate the natural history of PID, incorporating the severity of infection, number of recurrent episodes, treatment setting, and the risk over time of major complications. Clinical and cost data were from the published literature. Model outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs.

RESULTS

In a cohort of 100,000 females acquiring PID between 20 and 24 years of age, 8550 ectopic pregnancies, 16,800 cases of infertility, and 18,600 cases of chronic pelvic pain were projected to occur. Assuming a 3% annual discount rate, we found the average per-person lifetime cost to be $2150. Average lifetime costs for women who developed major complications were $6350 for chronic pelvic pain, $6840 for ectopic pregnancy, and $1270 for infertility. The majority of costs (79%) were accrued within 5 years of upper genital tract infection. Results were most sensitive to assumptions about the timing of major complications and the discount rate.

CONCLUSION

The average per-person lifetime cost of PID ranges between $1060 and $3180. Future cost-effectiveness analyses of STD screening programs can include this range as a reasonable upper and lower bound. These findings suggest successful PID prevention efforts may avert substantial costs for care providers such as managed care organizations while providing well documented clinical benefits for women in the United States.

Performance of the APTIMA Combo 2 assay for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in female urine and endocervical swab specimens

The greater sensitivity of nucleic acid amplification tests (NAATs) for Chlamydia trachomatis and Neisseria gonorrhoeae permits the use of urine and other noninvasive specimens, which can increase the reach and decrease the costs of public health screening programs aimed at controlling these infections. This study evaluated the performance of the APTIMA Combo 2 assay, a multiplex assay based on the transcription-mediated amplification reaction, for the simultaneous detection of both pathogens in endocervical swab and urine specimens from females. Combo 2 assay results were compared with patient infected status, which were available by using other commercial NAATs. Sensitivity and specificity for C. trachomatis were 94.2 and 97.6%, respectively, in swabs and 94.7 and 98.9%, respectively, in first-catch urine (FCU). Sensitivity and specificity for N. gonorrhoeae were 99.2 and 98.7%, respectively, in swabs and 91.3 and 99.3%, respectively, in FCU. The assay reliably detected both infections in coinfected patients. The Combo 2 assay can be recommended for use with endocervical swab and urine specimens from females, especially for screening tests for asymptomatic women in sexually transmitted disease surveillance programs. This Food and Drug Administration-cleared assay can be a useful tool in efforts to reduce the prevalence and incidence of C. trachomatis and N. gonorrhoeae infections in sexually active women and to prevent their costly and serious sequelae.

Cost effectiveness of screening for Chlamydia trachomatis: a review of published studies

OBJECTIVE

Screening for Chlamydia trachomatis in the lower genital tract may contribute to the prevention of pelvic inflammatory disease in women. The purpose of this review was to critically appraise, and summarise studies of the cost effectiveness of screening for C trachomatis.

METHODS

A literature search was conducted on Medline and in Health Star from 1990-2000. Keywords were C trachomatis, screening, cost effectiveness. Bibliographies of reviewed articles were also searched. The population studied was asymptomatic sexually active women under 30 years of age in a primary care setting. The intervention assessed was screening for lower genital tract infection with C trachomatis and the outcomes studied were cases of C trachomatis detected, cases of PID prevented, and associated costs. Studies were assessed using the Drummond criteria for economic evaluations. They were assessed qualitatively as they were too heterogeneous to allow quantitative analysis.

RESULTS

10 studies were included. All were modelled scenarios and all found screening to be more cost effective than simply testing symptomatic women, although all were based on probabilities that were assumed. Six of the studies focused on DNA based testing, three of them using urine. The models showed screening to be cost effective at prevalences of 3.1-10.0%, and cost saving (overtesting symptomatic women) at a prevalence as low as 1.1%, if age was used as a selection factor and DNA based tests were used in urine samples.

CONCLUSIONS

At the prevalence of infection expected in the target population, all studies suggest screening is cost effective. However, the assumptions used in the models have been difficult to confirm and there is a need for more data, particularly on the risk of complications in women with asymptomatic lower tract infection.

Provider willingness to screen all sexually active adolescents for chlamydia

OBJECTIVES

To assess differences in provider willingness to screen all sexually active male and female adolescents for chlamydia and to determine whether concerns about cost effectiveness of screening are related to provider willingness to screen for chlamydia.

METHODS

All primary care providers in a managed care organisation self administered a survey about screening all sexually active adolescents for chlamydia.

RESULTS

Respondents were 217 physicians (MDs) and 121 nurse practitioners (NPs) or physician assistants (PAs). Excluding obstetrician/gynaecologists, more providers were willing to routinely screen adolescent females than males for chlamydia (67% v 49% respectively; p<0.001). Independent predictors of provider willingness to screen both males and females included belief that routine screening is cost effective and being a NP/PA v an MD. Belief that chlamydia screening is easier in females than males independently predicted less willingness to screen males.

CONCLUSION

Information that reduces provider concern about the cost effectiveness of screening may increase provider willingness to screen adolescents for chlamydia. Availability of urine based tests may reduce provider beliefs that females are easier to screen than males and increase chlamydia screening in males.

The Use of Urine and Self-obtained Vaginal Swabs for the Diagnosis of Sexually Transmitted Diseases

Studies have reported that self-collected specimens, such as urine or vaginal swabs, can be successfully used to diagnose sexually transmitted infections when they are used with nucleic acid amplification assays. This eliminates the necessity for a clinician-performed pelvic examination for women, or a urethral swab for men, for sample collection. These nucleic acid amplification assays used with self-collected specimens are highly sensitive and specific, and their use may be extended to broad nonclinic screening venues, where their use can augment public health programs designed to control the epidemic of sexually transmitted diseases.

A comparison of two methods for detection of Chlamydia trachomatis in the male urethra

Several methods have been put forward for screening people for Chlamydia trachomatis infection of the urogenital tract. It is often believed that culture is the gold standard. However, newer and faster methods are being developed. This study reports the result from the comparison of two methods.

Hospitalization rates in female US Army recruits associated with a screening program for Chlamydia trachomatis

BACKGROUND

A volunteer program to test non-healthcare-seeking women for genital Chlamydia trachomatis infection was instituted at the US Army's largest basic training center and evaluated for its effectiveness in reducing sequelae.

GOAL

To compare hospitalization rates between women with positive test results for C trachomatis and those with negative results, and between women tested and those not tested for C trachomatis.

STUDY DESIGN

For this study, 28,074 women who entered the Army in 1996 and 1997 were followed for hospitalizations through December 1998. Of these women, 7053 were tested for C trachomatis, and 21,021 were not screened. Hospital admissions were calculated per person-year, and adjusted relative risks were determined.

RESULTS

The overall prevalence of C trachomatis in the screened group was 9.1%. The relative risk of hospitalization for pelvic inflammatory disease in the screened cohort was 0.94 (95% CI, 0.69-1.29), as compared with those not screened. The relative risk of hospitalization for any reason was 0.94 (95% CI, 0.90-0.99). Among women screened, no difference was found in pelvic inflammatory disease hospitalizations between women with positive test results who were being treated for C trachomatis and those with negative test results.

CONCLUSIONS

The investigated C trachomatis intervention program for female Army recruits was associated with a lower overall hospitalization rate in screened volunteers, as compared with unscreened women. The pelvic inflammatory disease hospitalization rate in women with C trachomatis who were screened and treated was similar to that observed in uninfected women.

Multicenter evaluation of the BDProbeTec ET System for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in urine specimens, female endocervical swabs, and male urethral swabs

The performance of the Becton Dickinson BDProbe Tec ET System Chlamydia trachomatis and Neisseria gonorrhoeae Amplified DNA Assays (BD Biosciences, Sparks, Md.) was evaluated in a multicenter study. Specimens were collected from 2,109 men and women, with or without symptoms, attending sexually transmitted disease, family planning, and obstetrics and gynecology clinics. Both swab and urine samples were collected, and the results obtained from 4,131 specimens were compared to those from culture and the LCx nucleic acid amplification test (Abbott Industries, Abbott Park, Ill.). PCR and cytospin of the culture transport medium with chlamydia direct fluorescent antibody staining were used to adjudicate chlamydia culture-negative results. Sensitivity and specificity were calculated both with and without use of the amplification control (AC), with little apparent difference in the results. Without the AC result, sensitivity for C. trachomatis and N. gonorrhoeae were 92.8 and 96.6%, respectively, for cervical swabs and 80.5 and 84.9% for urine from women. C. trachomatis and N. gonorrhoeae sensitivities were 92.5 and 98.5%, respectively, for male urethral swabs and 93.1 and 97.9% for urine from men. This amplified DNA system for simultaneous detection of chlamydial and gonococcal infections demonstrated superior sensitivity compared to chlamydia culture and has performance characteristics comparable to those of other commercially available nucleic acid-based assays for these organisms.

Point-of-entry screening for C. trachomatis In female army recruits. Who derives the cost savings?

BACKGROUND

Screening women for genital Chlamydia trachomatis at entry to military service provides an opportunity to reduce costs associated with sequelae of this infection. However, financial responsibility for screening may be debated. More than 50% of recruits return to civilian life within 2 years. The military and the civilian health care systems would both benefit from a screening program.

OBJECTIVE

To assess the cost-effectiveness and relative cost savings to the military and civilian health sectors of three screening strategies for U.S. Army female recruits for C. trachomatis using urine ligase chain reaction: screening all recruits, screening recruits aged < or = 25 years, and no screening.

METHODS

We applied a decision analytic model. Cost factors included screening, lost military training, morbid pelvic inflammatory disease, and other sequelae. Using a 5-year analytic horizon, we conducted analyses from military and civilian perspectives.

RESULTS

Screening 10,000 female army recruits would cost 193,500 dollars and prevent 282 cases of sequelae, with a projected savings of 53,325 dollars to the military and 505,053 dollars to the civilian sector. From a military perspective, screening women aged < or = 25 years provided the highest cost savings. Screening all female recruits incurred an incremental cost of $1199 per sequela prevented. From a civilian perspective, screening all recruits offered the greatest cost savings.

CONCLUSIONS

Screening female Army recruits for C. trachomatis offers substantial savings in health care costs for both the military and civilian health care systems. Relative financial benefit derived from recruit screening is disproportionate; greatest cost savings are enjoyed by the civilian sector.

Cost-effectiveness of screening programs for Chlamydia trachomatis: a population-based dynamic approach

BACKGROUND

Models commonly used for the economic assessment of chlamydial screening programs do not consider population effects.

GOAL

To develop a novel dynamic approach for the economic evaluation of chlamydial prevention measures and to determine the cost-effectiveness of a general practitioner-based screening program.

STUDY DESIGN

The dynamic approach was used to estimate the cost-effectiveness of a screening program for the first 10 years of screening in The Netherlands. Screening involved a ligase chain reaction test on urine followed by standardized therapies and partner referral. Eligible persons were sexually active, 15 to 24 years, visited a general practitioner, and had no symptoms of sexually transmitted diseases. The heterosexual model population, which consisted of persons 15 to 64 years, had a total chlamydial prevalence of 4.1% before screening. Screening effects on chlamydial incidence were computed by using a population-based stochastic simulation model. Incidence data were connected with a decision analysis model to determine the health effects of the program. The net costs of the program were calculated (investment costs minus averted costs, in 1997 US$) from a societal perspective and expressed per major outcome averted (symptomatic pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy, infertility, neonatal pneumonia).

RESULTS

Unlike the standard static approach, our model adequately addresses dynamic processes such as chlamydial transmission and the impact of screening programs on chlamydial incidence in the population. During the first 10 years of screening, the investigated program yields savings of US $492 or US $1,086 per major outcome averted, excluding or including indirect costs, respectively. These results depend on chlamydial prevalence and partner referral.

CONCLUSIONS

The cost-effectiveness of chlamydial screening programs seems best to be determined by using dynamic modeling on a population basis. In addition to preventing negative health outcomes, the investigated screening program may save costs.